Nokea
Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed-----and will need to be monitored for-------
- A. Lithium toxicity
- B. Hyponatremia
- C. cardiac dysrhythmias
- D. nephrotoxicity
- E. metabolic alkalosis
- F. Hypertension
Correct Answer: A,D
Rationale: The correct answer is A and D. Lithium toxicity and nephrotoxicity are commonly associated with the use of lithium. The nurse needs to monitor the patient for signs and symptoms of lithium toxicity, such as tremors, confusion, and increased thirst, as well as signs of nephrotoxicity, like decreased urine output and electrolyte imbalances. Hyponatremia (B), cardiac dysrhythmias (C), metabolic alkalosis (E), and hypertension (F) are not directly related to lithium use. Monitoring for these conditions would not be the priority in a patient who has likely developed lithium toxicity and nephrotoxicity.
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For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at a high volume.
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices.
- D. Assess the client for suicidal ideation.
- E. Place the client in a room near the activity room
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale: Correct Answer: B, C, D indicated; A, E contraindicated
Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.
A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
- A. Contact the charge nurse to see if the prescription was changed
- B. Complete an incident report and place it in the client's medical record
- C. Submit a written warning for the nurse involved in the incident
- D. Compare the current infusion with the prescription in the client's medication record
Correct Answer: D
Rationale: The correct answer is D: Compare the current infusion with the prescription in the client's medication record. This is the best course of action as it allows the nurse to verify the accuracy of the IV infusion against the prescribed treatment plan. By cross-referencing the current infusion with the prescription in the client's medication record, the nurse can identify any discrepancies and take appropriate actions to ensure the client's safety and well-being.
Choice A is incorrect because contacting the charge nurse may not provide the necessary information to verify the accuracy of the IV infusion. Choice B is incorrect as completing an incident report is premature without first verifying the discrepancy. Choice C is inappropriate and punitive without a proper investigation. Choices E, F, and G are not provided in the question, so they are irrelevant.
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine is known to potentially cause liver injury. Monitoring liver function tests is crucial to detect any signs of liver damage early on. Kidney function tests (B), hemoglobin and hematocrit (C), and serum sodium and potassium (D) are not directly associated with atomoxetine use in ADHD. Monitoring liver function is the priority in this case.
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
- A. A noncoring needle
- B. An angiocatheter
- C. A butterfly needle
- D. A 25 gauge needle
Correct Answer: A
Rationale: The correct answer is A: A noncoring needle. This type of needle is specifically designed for accessing implanted venous access ports as it minimizes damage to the port septum, reducing the risk of infection and catheter damage. The noncoring needle has a special tip that creates a clean puncture without coring (cutting) the septum, ensuring proper access without compromising the integrity of the port.
Summary of why the other choices are incorrect:
B: An angiocatheter is not recommended for accessing venous access ports as it is not designed for this purpose and can cause damage to the port.
C: A butterfly needle is not suitable for accessing venous access ports as it can cause coring of the septum and increase the risk of infection.
D: A 25 gauge needle is too small and not suitable for accessing implanted venous access ports as it may not provide adequate flow rates and can lead to difficulty in accessing the port.
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?'
- B. Has anyone in your family committed suicide?'
- C. Is there anyone you would like involved in your care?'
- D. Are you thinking about ending your life?'
Correct Answer: D
Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.